How Abortion Providers Plan to Use Telehealth to Bolster Post-Roe Access

December 16, 2021 - The fate of Roe v Wade — the landmark 1973 case that led to the legalization of abortion in America — appears to be in jeopardy, and as a result, abortion providers are preparing for a world where abortion access is severely restricted in certain states. Among the many tools being employed to address this lack of access is telehealth.

On Dec. 1, the Supreme Court heard oral arguments in Dobbs v. Jackson Women’s Health Organization. At the center of the case is a Mississippi law that bans all abortions over 15 weeks except in the case of severe fetal abnormality and medical emergencies. If the court allows the law to stand, it will effectively overturn Roe v Wade, according to a Kaiser Family Foundation policy brief.

A decision is not expected until mid-next year, but with a conservative majority in the Supreme Court, abortion service providers are gearing up for a fight.

What a post Roe-world could look like

If federal abortion protections are overturned, about half of US states would significantly limit or eliminate access to abortion care, said Jenny Sheehan, telehealth program director at the National Abortion Federation, in an email.

This would occur as a patchwork of state laws. For example, 12 states have laws to ban most or all abortions that would be triggered if Roe were overturned, nine states have unconstitutional post-Roe restrictions that are currently blocked by courts, and seven states have laws that "express the intent to restrict the right to legal abortion to the maximum extent permitted by the U.S. Supreme Court in the absence of Roe," according to the Guttmacher Institute.

These laws will likely result in millions of people having to either travel hundreds of miles to get access to abortion services or be forced to carry a pregnancy to term, Sheehan noted.

"We can expect to see worse health outcomes and increasing economic hardship for pregnant people in states that limit abortion access," she said. 

Also, not all pregnant people have the means to travel across state line to receive abortion care.

"The populations that will be most impacted are people of color and people of lower socioeconomic statuses, worsening existing inequities," said Deyang Nyandak, MD, a family medicine physician in the Boston area and a fellow with Physicians for Reproductive Health, in an email. "People who are unable to pay for traveling, arrange childcare and take time off from work will suffer the most."  

Not only will underserved people bear the brunt of the fallout from Roe v Wade being overturned, but health systems in states where abortions remain legal may have to brace for an increase in patient volume, which could cause a strain on resources, Nyandak said.

How abortion providers are incorporating telehealth into their response

Abortion access has been under siege for years, with anti-abortion efforts ramping up under the most recent White House led by former President Donald Trump.

Nyandak's Massachusetts-based practice has been working on ways to ensure widespread access to safe and equitable abortion care, including expanding the number of primary care practices that offer abortion services and making telehealth medication abortions available to eligible patients.

The practice began providing medication abortions via telehealth during the COVID-19 pandemic. In April, the Food and Drug Administration temporarily lifted the in-person dispensing requirement for mifepristone, one of the two drugs taken for medication abortions, during the public health emergency. This enabled providers to evaluate their patients and prescribe the medication virtually. The FDA permanently lifted the requirement Dec. 16.* 

"The [Risk Evaluation and Mitigation Strategies] restriction on mifepristone is not evidence-based but rather politically motivated and it was temporarily removed due to the COVID-19 pandemic allowing for telehealth medication abortions," Nyandak said. "The permanent removal of this restriction will allow healthcare providers to continue providing safe and effective service to our patients via telehealth."

Medication abortions facilitated via telehealth have been deemed safe. In an analysis of nearly 20,000 medication abortions, adverse events were rare, representing 0.3 percent of cases overall, and did not differ between those who choose telemedicine or in-person services, according to a practice bulletin released by the American College of Obstetricians and Gynecologists last October.

"Telehealth medication abortion removes the unnecessary burden placed on patients to be physically present at a medical center by allowing abortion providers to deliver the medications to the requested location in a safe and secure manner," Nyandak said.

Typically, patients can pick up the prescribed medication from clinics or have it mailed to them.

The organization is also offering follow-up appointments via telehealth to ensure that the patients completed their medication abortion, she said.

Nyandak is expecting an influx of patients from neighboring states if Roe is overturned. Telehealth abortions can help clinics deal with the expected jump in patient volume and ensure they provide care to the largest number of patients possible.

"We have seen the impact of this ban on Texas' neighboring states with decreased access to all patients due to increased need," she said. "Telehealth medication abortions allow increased access to patients who have difficulty traveling to the clinic due to any reason."

Melissa Grant, chief operations officer at reproductive health and abortion services provider Carafem, echoed Nyandak.

"Receiving a telemedicine visit just across the border in a blue state may improve the availability of care and decrease the costs associated with an in-person medical visit," she said in an email.

In addition to centering its health centers in states where abortion is likely to remain legal and in close proximity to states where restrictions are expected to increase, Carafem is expanding the availability of medically supported at-home abortion pills.

The organization currently provides at-home abortion pills in 10 states and the District of Columbia.

"There are many reasons a person may prefer to end their pregnancy at home with pills," Grant said. "Telemedicine visits allow a person to have greater privacy to choose who they want with them to support them when they end their pregnancy. It also allows people to choose the location and timing of their abortion and limits the need for travel to a health center."

The National Abortion Federation has been providing its members — which include private and non-profit clinics, Planned Parenthood affiliates, physicians' offices, and hospitals — with tailored technical assistance for incorporating telehealth into their operations since 2019.

"We offer direct operational support to help providers launch a telehealth strategy that will best meet their patients' needs," Sheehan said. "This work has been extremely important throughout the pandemic as providers try to keep patients and staff teams safe while providing essential healthcare services."

Next year, the federation plans to launch a telehealth platform specific to abortion care. NAF members will be able to use this system in states where abortion remains legal, helping alleviate the expensive and time-consuming process of vetting, purchasing, designing, and launching a telehealth system at their clinics.

What's needed at the regulatory level if Roe is overturned

The most important step that needs to be taken at the federal level to protect abortion rights regardless of Roe's fate is the passage of the Women's Health Protection Act by Congress, said Nyandak.

Further, state-level action is needed in the 19 states that outright ban or restrict the use of telehealth for abortion currently.

Ultimately, these regulatory changes are in the hands of lawmakers. But they can be swayed by the people they are elected to serve.

"People often do not think about the specifics of receiving an abortion until they or a loved one needs one," Carafem's Grant said. "It is important for the majority of people in this country who believe abortion should remain legal to step up and tell their elected officials that they feel this need is important. It can no longer be taken for granted that abortion will be available when and if you need one in the United States."